THE PULP THERAPY

LE ANH HONG DDS

 MỤC TIÊU

• 1. Trình bày được đặc điểm sinh học của mô tủy răng và ứng dụng vào các nguyên tắc của các
phương pháp điều trị bảo tồn tủy sống
• 2. Giải thích sự lựa chọn phương pháp điều trị tủy theo tình trạng bệnh lý tủy và giải phẫu chân
răng
• 3. Trình bày đặc tính của các vật liệu dùng trong các phương pháp điều tị bảo tồn tủy sống
• 4. Trình bày các yếu tố ảnh hưởng đến sự thành công và tiên lượng của các phương pháp che
tủy trực tiếp và gián tiếp
• 5. Vận dụng được trình tự thực hiện các kỹ thuật che tủy gián tiếp 1 lần hẹn, 2 lần hẹn, che tủy
trực tiếp vào các tình huống lâm sàng.
 CONTENT
• Features of the pulp
• Case selection of the pulp therapy
• The vital pulp therapy
• Factors affect to successful outcome
• Material used for vital pulp therapy
• Treatment Modalities: definition, goal, materials, procedure, indication and nonindication
• Indirect capping
• Direct capping
• Pulpotomy
• The non vital pulp therapy
• Apexification
• Apexogenesis
• Regenerative endodontic
• Pulpectomy / root canal treatment
TERMINOLOGY

• Pulp exposure: lộ tủy

• Pulp capping: che tủy
• Pulpotomy: cắt tủy/lấy tủy bán phần
• Pulpectomy : lấy tủy toàn bộ/ điều trị tủy chân
• Apexification: gây đóng chóp/ can chóp
• Apexogenesis: gây tạo chóp/sinh chóp
• Regeneration endodontics: nội nha tái sinh
 IMPORTANT FEATURES OF PULP
• Cannot visualization
• Radiolucent
• Pulp is a connective tissue with several factors making it unique and
altering its ability to respond to irritation - ability to form dentin
throughout life.
• Surrounded by a hard tissue →can’t expansion and restricts the pulp’s
ability to tolerate edema.
• Lacks true collateral blood supply.
• Once exposed, extremely sensitive to contact and temperature but this
pain does not last for more than 1 to 2 seconds after the stimulus
removed.
• Potential for regeneration and repair diminishes with age.
 PULPAL RESPONSE TO CARIES AND DENTAL
PROCEDURE
As the dentin thickness decreases, the pulp
response increases.
Remaining dentin thickness (RDT)
• In human teeth, dentin is
approximately 3 mm thick
• Dentin permeability increases with
decreasing RDT
• RDT of 2 mm or more effectively
precludes restorative damage to the
pulp
• At RDT of 0.75 mm, effects of
bacterial invasion are seen
• When RDT is 0.25 mm,
odontoblastic cell death is seen.
 DEFENSE MECHANISM OF PULP

• Tubular sclerosis
• Smear layer
• Reparative dentin formation
– Healthy reparative reaction
– Unhealthy reparative reaction
– Destructive reaction
 CASE SELECTION
Physical/Chemical/Thermal injuries Dental Caries

Pulpal Irritation

Inflammation

Reversible Irreversible
Vital pulp
therapy
Non-vital
Repair Pulp necrosis pulp therapy
 DEFINITION
“Vital pulp therapy is designed to preserve and maintain pulpal
health in teeth that have been exposed to trauma, caries,
restorative procedures, and anatomic anomalies.”
(Cohen’s Pathway of the pulp,11ed,p849)

• The prime objective in vital pulp therapy is to initiate the formation of tertiary
reparative dentin or calcific bridge formation.
• This procedure is essential for the preservation of involved immature
permanent teeth where root development may be incomplete and preservation
of arch integrity is critical during maxillofacial development.
• The treatment can be completed for permanent teeth that show reversible
pulpal injuries, and the outcomes depend on a variety of factors.
OUTCOMES DEPEND ON A VARIETY OF FACTORS

Diagnosis
& case
Restorative selection
materials Hemostasis

Successful
outcome Caries
Bonded removal
composites

Bioactive Magnificaiton
capping systems
materials
 MATERIALS USED FOR VITAL PULP THERAPY
Cohen and Combe have given the
requirements of an ideal pulp capping
agent:
• It should maintain pulp vitality.
• It should stimulate reparative dentin
formation.
• It should be either bactericidal or
bacteriostatic in nature and should be
able to provide bacterial seal.
• It should adhere well to both the dentin
and the overlying restorative material.
• It should be able to resist the forces
under the restoration during the lifetime
of the restoration.
• It should be sterile. Ideal properties of a pulp capping agent.
• It should be preferably radiopaque.
MATERIALS USED FOR VITAL PULP THERAPY
 CALCIUM HYDROXIDE
- In 1920, Hermann introduced a calcium
hydroxide mixture that induced bridging of the
exposed pulp with reparative dentin.
- Calcium hydroxide has the unique potential to
induce mineralization even in tissues that have
not been programmed to mineralize.
- Calcium hydroxide is an initiator rather than a
substrate for repair.
- Hard-setting calcium hydroxide preparations
are recommended, as these cements release
fewer hydroxyl ions than pure calcium hydroxide
and are gentler to the pulp.
Mechanism of action of calcium hydroxide.
 Calcium Hydroxide

• Desirable characteristics of CH include an initial high alkaline pH, which is responsible for stimulating
fibroblasts and enzyme systems.
• It neutralizes the low pH of acids, shows antibacterial properties, and promotes pulp tissue defense
mechanisms and repair.
• The drawbacks of CH include weak marginal adaptation to dentin, degradation and dissolution over
time, and primary tooth resorption.
• Reparative bridge formation subjacent to CH can also be characterized by tunnel defects.
• Histologically, CH demonstrates cytotoxicity in cell cultures and has been shown to induce pulp cell
apoptosis.
 MINERAL TRIOXIDE AGGREGATE (MTA)

• In 1993, Mohammad Torabinejad centered his

research in the development of MTA at the
Loma Linda University, California .
• Commercial MTA exists in both gray and white
forms
• Composition :
• Tricalcium silicate
• Dicalcium silicate
• tricalcium aluminate
• Tetracalcium aluminoferrite (present only
in Grey MTA)
• Bismuth oxide (added to the cement as a
radiopacifier)
• MTA not only appears to demonstrate
acceptable biocompatible behavior but also
exhibits acceptable in vivo biological
performance when used for root-end fillings,
perforation repair, pulp capping, pulpotomy,
and apexification treatment. The setting reaction of MTA
MINERAL TRIOXIDE AGGREGATE (MTA)

Advantages
• Produces more dentinal bridging with superior structural integrity than Ca(OH)2
in a shorter time span with significantly lesser inflammation.
• Has a superior ability to resist the future penetration of bacteria than Ca(OH)2.
• Has significant antimicrobial property on some of the facultative bacteria.
• Highly biocompatible with pulpal and periodontal tissues
• Hydrophilic—sets hard in the presence of water
• Set MTA is alkaline (pH of 12.5) and may induce dentinogenesis.
• The presence of blood has little impact on the degree of leakage of MTA
 BIODENTINE

• Composition
Powder
– Tricalcium silicate
– Dicalcium silicate
– Calcium carbonate
– Zirconium dioxide
Liquid
– Calcium chloride in aqueous solution with an admixture of polycarboxylate
• Setting reaction
▪ The powder is dispensed in a capsule that is mixed with the liquid in a triturator
for 30 seconds.
▪ Hydration of the tricalcium silicate produces a hydrated calcium silicate gel and
calcium hydroxide. The unreacted tricalcium silicate grains are surrounded by
layers of calcium silicate hydrated gel, which are relatively impermeable to water,
thereby slowing down the effects of further reactions.
▪ Biodentine sets in approximately 10 minutes (no salivary contamination )
 BIODENTINE

Advantages
• Biodentine can be used for pulp capping and to bulk fill the cavity.
• It does not stain the tooth. It has excellent radiopacity.
• There is no need for surface preparation or tedious bonding due to the
micromechanical anchorage.
• Biodentine has higher compressive strength than dentin, preserves pulp, and
promotes pulp healing.
• The microleakage resistance is enhanced by the absence of shrinkage due to
the resin-free formula.
 TREATMENT MODALITIES
• Pulp treatment modalities can be classified into 2 categories
• Vital pulp therapy
• 1. Indirect pulp capping Based on the understanding that
pulp tissue has an innate potential
• 2. Direct pulp capping for repair in the absence of
• 3. Pulpotomy → Pediatric dentistry bacterial contamination

• 4. Apexogenesis → Pediatric dentistry

• Non vital pulp therapy
• 1.Apexification → Pediatric dentistry
• 2.Regeneration → modern dentistry
• 3.Pulpectomy → Pediatric dentistry
• 4. Root canal treatment (*)
REVERSIBLE IRREVERSIBLE
PULPITIS PULPITIS

Vital pulp therapy Close apex Open apex

- Indirect capping -Pulpectomy - Apexification

- Direct capping - Root canal - Regenerative
- Pulpotomy treatment endodontic
- Apexogenesis
 INDIRECT PULP CAPPING

• Definition:
Indirect pulp capping is defined as a procedure wherein the deepest layer of the
remaining affected carious dentin is covered with a layer of biocompatible material in
order to prevent pulpal exposure and further trauma to the pulp

• Objective:
- to preserve the vitality of the pulp
- completely remove the carious-infected dentin
- form tertiary dentin.
INDIRECT PULP CAPPING
 INDIRECT PULP CAPPING
CLINICAL PROCEDURE

• Indirect pulp capping can be performed as a singleor two-step approach (stepwise excavation)
• Stepwise excavation is a technique in which caries is removed in increments in two or more
appointments over a period of few months instead of trying to remove the caries in a single
sitting.
• The two-step stepwise excavation approach is recommended for the following reasons:
✓ A two-step approach avoids unintentional pulpal exposure which may deteriorate the pulpal
prognosis.
✓ The dentist gets a chance to assess the reaction of the tooth as well as gain information of the
changes in caries activity.
✓ Two-step appointment gives an opportunity to remove the slowly progressing lesion in slightly
infected, discolored, demineralized dentin before the placement of the final restoration.
✓ The final excavation of the caries is safer in the second sitting as it is easier to remove the dry
carious dentin.
Differences between infected and affected dentin
Soft infected dentin remaining at Infected and affected dentin removed at the
the dentin-enamel junction. dentin-enamel junction with a round bur.

Peripheral sound dentin achieved, with

some unsupported enamel at the margins.
 Carious tissue removal:
A:Creation of peripheral
sound dentin with a
round bur
B: thin layer of infected
dentin on pulpal floor
C: removal of infected
dentin
D: affected dentin on
pulpal floor
E:removal of affected
dentin [not
recommended]
F:near exposure of pulp
chamber to reach sound
dentin
 The two most important factors determining the
success of indirect pulp capping

• Remaining dentin thickness (RDT): 2.0–0.5 mm has a good prognosis

• The rate of reparative dentin deposition has been shown to average
1.4 µm/day after cavity preparations in dentin of human teeth. The
rate of reparative dentin formation decreases markedly after 48 days.
• Choice of an indirect pulp capping agent : calcium hydroxide
 INDIRECT PULP CAPPING

• Success rate
- 99% success for avoiding pulp exposure
- 92% success- 3,5-4,5 year follow up
- Failed indirect pulp therapy means irreversible pulpal disease
 Indirect capping VS
Liner and base in deep
restoration
In a tooth with a normal pulp, when
caries is removed for a restoration, a
protective liner may be placed in the
deep arear of the preparation to
- Minimize pulp injury
- Promote pulp tissue healing, and
- To minimize postoperative sensitivity
Objectives:
- Tooth’s vitality
- Pulp tissue healing
- Tertiary dentin formation
Material
calcium hydroxide, dentin bonding agent
or glass ionomer cement
EFFECT OF
REMAINING
DENTIN
THICKNESS
ON TOOTH
 CASE SELECTION
Physical/Chemical/Thermal injuries Dental Caries

Pulpal Irritation

Inflammation Normal pulp

Reversible Irreversible Liners, Bases, Protecting

Cavity varnishes pulp
Vital pulp
therapy
Non-vital
Repair Pulp necrosis pulp therapy
 CLINICAL MANAGEMENT OF PULPAL EXPOSURE
Treatment options for an
exposed pulp:
I. Direct pulp capping
II. Pulpotomy
A. Partial/Cvek pulpotomy
B. Full pulpotomy
III. Pulpectomy
Factors Affecting Prognosis of Pulpal
Exposures:
- Pulpal exposure due to traumatic injuries
is more favorable than carious pulpal
exposure.
- Control of the hemorrhage is achieved in
10 minutes.
- Size of the exposure is less than 1 mm.
- Treatment is done within 48 hours of
exposure.
Clinical decision making chart for management of pulpal exposure
 DIRECT PULP CAPPING

• Definition: Direct pulp capping is defined as a procedure in which

the exposed vital pulp is covered with a protective dressing or base
placed directly over the site of exposure in an attempt to preserve
pulpal vitality.

• Objective:
• maintain vitality of tooth
• create new dentin in the area of the exposure and subsequent
healing of pulp
 DIRECT PULP CAPPING
Indications Contra indication
• Asymptomatic (no spontaneous pain, normal • Severe tooth ache at night
response to thermal testing, and pulp is vital • Spontaneous pain
before the operative procedure) • Tooth mobility
• Small exposure, less than 0.5 mm in • Radiographic apperance of pulp
diameter periradicular degeneration
• Hemorrhage from the exposure site is easily • Excess of hemorrhage at the
controlled (within 10 minutes) time of exposure
• The exposure occurred is clean and • Internal and external root
uncontaminated (rubber dam isolation) resorption
• Atraumatic exposure and little desiccation of
the tooth with no evidence of aspiration of
blood into the dentin (dentin blushing)
TECHNIQUES
OF DIRECT
PULP CAPPING
TECHNIQUES
OF DIRECT
PULP
CAPPING

Clinical Protocol for Direct

Pulp Capping
- calcium hydroxide
technique
- MTA technique.
FACTORS AFFECTING PROGNOSIS OF
DIRECT PULP CAPPING
 PULPOTOMY

• Definition: Pulpotomy is defined as a procedure in which a portion of

the exposed coronal vital pulp is surgically removed as a means of
preserving the vitality and function of the remaining radicular portion.
• Objectives
• Preservation of vitality of the radicular pulp
• Relief of pain in patients with acute pulpalgia and inflammatory
changes in the tissue:
• Ensuring the continuation of normal apexogenesis in immature
permanent teeth by retaining the
vitality of the radicular pulp
 PULPOTOMY
Indications
• Mechanical or carious exposure in
permanent teeth with incomplete
root formation.
• Traumatic exposures of longer
duration where coronal pulp is
likely to be inflamed in young
permanent teeth.
• in pulpally involved permanent
teeth of children in which the root
apex is not completely formed
Contraindications
• Patients with irreversible pulpitis
• Abnormal sensitivity to heat and cold
• Chronic pulpalgia
• Tenderness to percussion or palpation
because of pulpal disease
• Periradicular radiographic changes
resulting from extension of pulpal
disease into the periradicular tissues
• Marked constriction of the pulp
chamber or root canals (calcification)
 PROGNOSIS OF PULPOTOMY

The success of this procedure depends upon the following:

• Vitality of the majority of the radicular pulp
• Absence of adverse clinical signs or symptoms such as prolonged
sensitivity/pain or swelling
• No radiographic evidence of internal resorption or abnormal canal
calcifications
• No breakdown of periradicular supporting tissues
• No harm to succedaneous teeth
 CLASSIFICATION OF PULPOTOMY
• Amount of pulpal tissue removed
• A. Partial pulpotomy (Cvek’s pulpotomy)
• B. Complete pulpotomy (cervical pulpotomy)
• Type of medicament employed
• A. Calcium hydroxide pulpotomy
• B. MTA pulpotomy
• C. Formocresol pulpotomy
 Posterior pulpotomy:
(a) The rubber dam is applied.
(b) Access is gained into the pulp
chamber.
(c) The coronal portion of the pulp is
removed with a sharp spoon excavator.
(d) The pulp chamber is irrigated with
6% sodium hypochlorite and is dried
with a sterile cotton pledget.
(e) Calcium hydroxide/MTA paste is
applied to the pulp stump.
(f) A resin-modified glass
ionomer/flowable compomer base is
applied.
(g) The tooth is restored by permanent
restoration.
 PROGNOSIS

The success of pulpotomy depends upon the following:

• Vitality of the majority of the radicular pulp
• Absence of adverse clinical signs or symptoms such as prolonged
sensitivity/pain or swelling
• No radiographic evidence of internal resorption or abnormal canal
calcifications
• No breakdown of periradicular supporting tissues
• No harm to succedaneous teeth
 OPEN APEX

Vital pulp Non-vital

pulp

apexogenesis apexification

regenerative
endodontic
 APEXOGENESIS – KÍCH TẠO CHÓP

Apexogenesis is a
treatment designed to
preserve vital pulp tissue
in the apical part of a
root canal so that
formation of the root
apex may be completed
 APEXOGENESIS – KÍCH TẠO CHÓP

Deep pulpotomy for apexogenesis in an immature Apexogenesis after deep calcium hydroxide pulpotomy
maxillary central incisor on a mandibular permanent molar
 APEXIFICATION
(GÂY ĐÓNG CHÓP)

• Definition: Apexification is
defined as a method to
induce a calcific barrier
across an open apex of an
immature, pulpless tooth.
• Objective:
to induce either closure of the
open apical third of the root
canal or the formation of an
apical “calcific barrier” against
which obturation can be
achieved
.A . B . C . D

. E . F . G
(Courtesy: Jason J. Hales, USA)
 A B C D

(a) Maxillary central incisor with open apex.

(b) Single-visit MTA apical barrier created.
(c) Obturation completed with thermoplasticized obturation.
(d) One-year follow-up showing the tooth being clinically and radiographically asymptomatic.
(Courtesy: Julian Webber, England.)
REGENERATIVE ENDODONTICS
PULPECTOMY – PRIMARY ROOT CANAL TREATMENT
TEETH – PERMANENT TEETH
 CONCLUSION
• Diseases affecting the hard tissue of the tooth as well as most operative
procedure are traumatic to the pulp.
• Though the pulp has remarkable recuperative powers all efforts must be made
to minimise ínults to it
• Hence a gentle approach to cavity preparation and restoration should be
employed
• An accurate diagnosis of the pulpal status and case selection plays a major role
in the predictable outcome of vital pulp therapy procedures
 REFERENCES

• Nisha Garg, Amit Garg (2019). Textbook of Endodontics,4th , Jaypee Brothers

Medical Publishers
• Kenneth M. Hargreaves, Louis H.Berman (2016 ). Cohen’s Pathways of the
pulp, 11th, Elsevier
• Gunnar Bergenholtz, Preben Horsted-Bindslev, Claes Reit (2010). Textbook of
Endodontology, Willey Blackwell.
• B. Suresh chandra ,V. Gopikrishna (2014), Grossman’s Endodontic Practice,
13th, Wolters Kluwer Health